Bacterial vaginosis (BV) is treated with prescription antibiotics, but keeping it from coming back often requires a combination of lifestyle changes and, in some cases, partner treatment. Up to 66% of women experience a recurrence within a year of their initial treatment, so understanding the full picture matters more than just filling a prescription.
Why BV Keeps Coming Back
BV happens when the balance of bacteria in the vagina shifts. Beneficial bacteria that produce lactic acid and hydrogen peroxide get crowded out by harmful organisms, particularly one called Gardnerella vaginalis. What makes BV so stubborn is that these harmful bacteria form biofilms, which are structured colonies that coat the vaginal lining and encase themselves in a protective shell made of carbohydrates and proteins.
This biofilm acts as a physical barrier against antibiotics. Even at clinical doses, standard antibiotics can kill the free-floating bacteria but often fail to penetrate and eliminate the biofilm itself. That means the colony can regrow after treatment ends, which is the primary reason recurrence rates are so high. One lab study found that the concentration of metronidazole needed to eradicate an established biofilm was more than 16 times higher than what’s needed to stop bacterial growth alone.
Standard Antibiotic Treatment
The CDC lists three first-line options for treating BV: oral metronidazole taken twice daily for seven days, a vaginal metronidazole gel applied once daily for five days, or a vaginal clindamycin cream applied at bedtime for seven days. All three are considered equally effective for an initial episode.
If those don’t work or you can’t tolerate them, alternatives include oral clindamycin for seven days, vaginal clindamycin ovules for three nights, or a single-dose oral medication called secnidazole (granules you mix into applesauce or yogurt). There’s also tinidazole, taken orally for two to five days depending on the dose. Your provider will choose based on your symptoms, history, and whether you prefer an oral pill or a vaginal treatment.
Finishing the full course matters even if symptoms clear up early. Stopping partway through gives surviving bacteria, especially those protected by biofilm, a better chance of bouncing back.
Reducing Your Risk of Recurrence
Several behavioral factors disrupt vaginal flora and raise the risk of developing or re-developing BV. The CDC identifies douching, not using condoms, and having new or multiple sexual partners as the main ones. Douching is particularly harmful because it directly strips away protective bacteria, creating an opening for harmful organisms to take over. If you currently douche, stopping is one of the most effective things you can do.
Condom use during vaginal sex reduces the introduction of bacteria that can shift your vaginal balance. This is true even in long-term, monogamous relationships where BV keeps recurring. Limiting your number of sexual partners also lowers your overall exposure to bacteria that can disrupt your flora.
Partner Treatment: A New Recommendation
For years, treating male sexual partners wasn’t part of BV management because earlier data didn’t show a clear benefit. That changed in late 2025, when the American College of Obstetricians and Gynecologists recommended concurrent partner treatment for recurrent BV for the first time. The recommendation follows growing evidence that sexual activity plays a significant role in reinfection, with male partners potentially harboring the same bacteria on penile skin and under the foreskin.
If you’re dealing with recurrent BV in a relationship with a male partner, ask your provider about this option. Research is still limited for people with same-sex partners or those in nonmonogamous relationships, so recommendations for those situations are still evolving.
Boric Acid for Recurrent BV
Boric acid vaginal suppositories have gained attention as an add-on therapy, particularly for recurrent cases. The typical approach involves an “induction” phase of daily vaginal boric acid for 7 to 14 days, followed by a maintenance regimen of two to three times per week. Doses are generally 300 to 600 mg per suppository. About a third of women in one clinical review were also prescribed a standard antibiotic alongside the boric acid induction phase.
The exact mechanism isn’t fully understood, but boric acid appears to inhibit the growth of both bacteria and yeast and may help break down biofilms. It’s not a standalone replacement for antibiotics during an active infection, but it may help extend the time between recurrences when used as maintenance. Boric acid suppositories are for vaginal use only and should never be taken orally.
Probiotics and Vaginal Flora
Probiotics containing Lactobacillus strains are widely marketed for vaginal health, but the evidence is more nuanced than supplement labels suggest. Two well-studied strains, Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14, have shown the ability to reduce vaginal colonization by harmful organisms in clinical trials. These strains work partly by physically aggregating around harmful bacteria and yeast, blocking them from attaching to vaginal tissue.
However, most of the strong evidence for these strains relates to yeast infections rather than BV specifically. Oral or vaginal probiotics may support recovery alongside antibiotics, but they haven’t been proven to clear BV on their own. If you want to try them, look for products that list specific strains (not just “Lactobacillus”) and use them as a complement to, not a substitute for, prescribed treatment.
BV During Pregnancy
BV during pregnancy is associated with a higher risk of preterm delivery, meaning delivery before 37 weeks. Preterm birth carries serious risks for babies, including breathing problems, brain bleeding, and in severe cases, death. The relationship between BV and preterm delivery is still not fully understood as a direct cause-and-effect, but the association is strong enough that symptomatic BV in pregnancy is routinely treated.
If you’re pregnant and notice the characteristic thin, grayish-white discharge with a fishy odor, getting tested promptly allows for early treatment. The antibiotic options during pregnancy are generally the same, though your provider will weigh safety considerations specific to your trimester.
Recognizing BV Symptoms
BV doesn’t always cause noticeable symptoms, but when it does, the most common signs are a thin, off-white or grayish discharge and a fishy odor that often becomes stronger after sex. Some women also notice mild itching or burning during urination, though these are less typical than with yeast infections. The absence of thick, cottage cheese-like discharge and intense itching is what generally distinguishes BV from a yeast infection.
A healthy vaginal pH is typically below 4.5. BV pushes it higher, which is why some at-home pH test strips can flag a potential problem. But an elevated pH alone doesn’t confirm BV, since other conditions like trichomoniasis can also raise it. A provider can confirm the diagnosis with a swab and microscopic exam or a lab test.